understandings of ethics in maternal health care: an exploration of evidence from four districts in...

7/27/2019 Understandings of Ethics in Maternal Health Care: an Exploration of Evidence From Four Districts in Tanzania

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Understandings o Ethics in

Maternal Health Care: an Exploration

o Evidence From Four Districts in

Tanzania

Paper 2 rom the Ethics, Payments and

Maternal Survival Project

By Paula Tibandebage*, Tausi Kida** Maureen Mackintosh***

and Joyce Ikingura****

*REPOA), Tanzania

** Economic and Social Research Foundation (ESRF), Tanzania

***The Open University, United Kingdom

****National Institute for Medical Research (NIMR), Tanzania

Working Paper 13/2


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Published or: REPOA

P.O. Box 33223, Dar es Salaam, Tanzania

157 Mgombani Street, Regent Estate

Tel: +255 (0) 22 2700083 / 2772556

Fax: +255 (0) 22 2775738

Email: [email protected]

Website: www.repoa.or.tz

Design: FGD Tanzania Ltd

Suggested Citation:

Paula Tibandebage, Tausi Kida, Maureen Mackintosh and Joyce Ikingura Understandings of Ethics

in Maternal Health Care: an Exploration of Evidence From Four Districts in Tanzania.

Working Paper 13/2, Dar es Salaam, REPOA

Suggested Keywords:

Maternal Health Care, Maternal Health Survival, Ethics, payments, Empowering nurses

REPOA, 2013

ISBN: 978 9987 615 44 5

All rights reserved. No part o this publication may be reproduced or transmitted in any orm or by

any means without the written permission o the copyright holder or the publisher.

Ethics, Payments and Maternal Survival Project - Paper 2


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iv

Acknowledgements .......................................................................................................... iii

Table o Contents .............................................................................................................. iv

Abstract .............................................................................................................................. v

Acronyms ........................................................................................................................... vi

1.0 Introduction ............................................................................................................. 1

2.0 Theory and Methods ............................................................................................... 2

2.1 Medical and Nursing Ethics .............................................................................. 2

2.2 Methods .......................................................................................................... 3

3.0 Understandings o Ethical Maternal Care: Responses rom Interviews with

Women ..................................................................................................................... 6

3.1 Principles o Medical Ethics .............................................................................. 6

3.2 Relational or Caring Ethics ............................................................................... 7

3.3 Contextual Ethics ............................................................................................. 9

4.0 Understandings o Ethical Maternal Care: Responses rom interviews with

Nurses, Midwives and Clinical Ofcers ................................................................ 11

4.1 Those in Charge o Maternal Care .................................................................... 11

4.2 Midwives .......................................................................................................... 17

5.0 Discussion ............................................................................................................... 23

Reerences ......................................................................................................................... 26

Publications by REPOA .................................................................................................... 28

Table o Contents


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What is ethical maternal health care? This paper describes and refects upon the unprompted

responses to this question by women who were pregnant and/or had given birth, and by maternal

health care sta, in our districts o Tanzania. The paper draws on data rom a research project on

Ethics, Payments and Maternal Survival.. This is the third o a series o papers providing the ndings

o the project. In analysing the qualitative data, we draw on literature rom medical and nursing

ethics, rom the eminist and philosophical literature on relational ethics and the role o emotions

in ethics. We nd that the predominant conceptions o ethical care among both the women and

maternal health care sta interviewed are relational, and that there is a strong shared view between

the two groups o respondents that contextual issues such as acute shortages o medical supplies

and skilled sta are o serious ethical concern.

Abstract


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vi

ANC Antenatal care

DHS Demographic and Health Survey

EmOC Emergency Obstetric Care

ESRC Economic and Social Research Council

ESRF Economic and Social Research Foundation

FBO Faith Based Organisation

MMR Maternal Mortality Ratio

NIMR National Institute or Medical Research

PNC Post-natal care

TDHS Tanzania Demographic and Health Survey

TSPA Tanzania Service Provision Assessment Survey

UN United Nations

UNFPA United Nations Population Fund

WHO World Health Organisation

Acronyms


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1

Among global health injustices, maternal mortality in Tanzania, as well as in many other low-income

Arican countries, stands out. Estimates rom Demographic and Health Surveys (DHS) in Tanzania

(1996 &2005) indicate that the maternal mortality ratio (MMR) increased rom 529 deaths per

100,000 live births in 1996 to 578 in 2004/05. More recent data suggest that the MMR may now be

decreasing, with the most recent national data (NBS and ICH Macro, 2011) estimating the MMR at

454 deaths per 100,000 live births. WHO and others. (2012) have revised the estimate downwards

to 460 deaths per 100,000 live births. Margins o error in MMR calculations, however, are wide, and

some estimates are much higher. For example, WHO et al in 2007 estimated the MMR in Tanzania

was1,500 per 100,000 live births.

Within Tanzania, striking inequalities in access to maternal health care during delivery by geographical

and socio-economic characteristics, such as area o residence (rural vs. urban), education level, andwealth status (Tibandebage and Mackintosh 2009) imply that MMR is likely to be higher among

poor, less educated women living in rural areas (Mbaruku et al 2003; Macleod and Rhode 1998).

Gendered health system ailures have helped to generate high MMR (Tibandebage and Mackintosh

2009).

Access to maternal health care is ormally ree in Tanzania. However, inormal charging, and

requirements to privately purchase supplies and tests, are widespread (Storeng et al 2008; Perkins

et al 2009; Kruk et al 2008). This is worrying, given that charging is known to reduce access to

maternal care especially among the poorest (McDonagh & Goodburn 2001).

Since haemorrhage has been identied as the leading cause o maternal death in sub-Saharan

Arica (SSA) ollowed by eclampsia, sepsis and obstructed labour (Ronsmans et al 2006; Khan et

al 2006), a central explanation o maternal death rates is womens lack o access to competent

emergency obstetric and medical care (EmOC) in the days ater giving birth. Facilities at all levels

are known to lack essential medicines, other essential supplies, and trained sta (TSPA 2006) with

lower level acilities being particularly weak (Urassa 1997; Nyamtema et al 2008). In Tanzania as

elsewhere in the sub-Saharan region stang levels and sta attitudes are particularly poor in

maternal health care. There are severe shortages o trained midwives, poor pay and conditions o

work, and recurrent attitudinal problems including a culture o poor even abusive attitudes to

women (Tibandebage & Mackintosh 2002, 2005; Mamdani & Bangser 2004; Grossman-Kendall et

al 2001; Kyomuhendo 2003; Murray & Pearson 2006; Jewkes et al 1998; Gerein et al 2006).

This paper draws on evidence rom a research project Ethics, payments, and maternal survival1.The

project explored the interactions between payment-based care and ethical/unethical behaviour. We

draw here on the project ndings concerning understandings o ethics by both women in need o

maternal health care and the nurses and nurse midwives who attend them.

1 Ethics, payments and maternal survival in Tanzania project has been unded by a grant rom the Wellcome Trust, which

has been channelled through REPOA.

1 Introduction


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2.1 Medical and Nursing EthicsWe cannot here survey the huge literature o medical and nursing ethics. Instead, we ocus on a

distinction between principle-based and relational ethics which we then explore within our empirical

data.

Principle-based rameworks

Many ethical rameworks within the eld o medicine share the characteristic that they ormulate

abstract principles intended to be o general application. Texts on medical ethics generally proceed

in this manner. They set out to provide a set oprinciples to guide behaviour, particularly o doctors,

though there are reerences to a wider range o medical proessionals. An infuential ormulation is aset o our principles (Beauchamp and Childress 2009: 13):

Respect or autonomy;

Non-malecence (do no harm);

Benecence (seek to do good);

Justice.

Beauchamp and Childress (2009) argue that these ideal principles are not absolute rules, rather

they are general norms o obligation (p.13) that guide the ormulation o more specic rules o

behaviour. Such rules may include, or example, condentiality, privacy and inormed consent, which

are all associated with respect or autonomy. The principles or moral norms may also conict:Principlesare not absolute merely because they are universal (p.15).

Thereore, this approach ormulates ideal principles and associated rules that should guide individual

clinicians behaviour. The nal principle, justice, however raises questions that include but also

go beyond ethical individual behaviour to address issues concerning priorities in the allocation o

resources and distribution o the benets o health care.

Theories o justice in health care may derive rom principles o human rights. The human right to

the highest attainable standard o health is legally protected by international human rights treaties,

and is also recognised in regional treaties and embedded in the constitutions and laws o manycountries (Hunt & Bueno de Mesquita, n.d.). A report to the UN Human Rights Council rom the

then UN Special Rapporteur on the right to health (Paul Hunt) argued that the right to the highest

attainable standard o health entitles women access to key reproductive health care services that

can prevent mortality (UN General Assembly, 2006). States have an obligation to progressively

realise this right.

Justice in health care may also derive rom principles o equity such as to each according to need.

In this account, ee-or-service charging can thereore be judged unethical since it is exclusionary and

hence contradicts that principle. Health systems have oten been the site o political eorts towards

greater social equality, drawing on discourses o social justice (Freedman, 2005; Mackintosh, 2001).

The concept o capabilities, in the work o philosopher Martha Nussbaum, and the economist AmartyaSen, provides another approach to equity. Society is seen as having a moral duty to establish or all

citizens a threshold level o capabilities (or opportunities) to unction as members o society. Such

capabilities include a lie not prematurely ended, bodily health and integrity, and having the social

basis or sel-respect and non-humiliation which in turn implies non-discrimination (Nussbaum,

2001, pp. 416-418). In this account, i charging is associated with humiliation, it is unethical even

when it is not exclusionary.

2 Theory and Methods


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Finally, a utilitarian set o principles aggregates benets o care to individuals on the basis o their

ability to benet. The use o aggregate burden o disease calculations to direct resource allocation

is an infuential example o this approach.

Relational ethics

Principle-based ethics can be contrasted with a second broad type o ethical reasoning that is

relational, culturally embedded, and a matter o personal morality (Geisman et al., 2008; Kleinman &

Benson, 2006).Agent-relative ethics allows that relationships and proximity may properly infuence

ethical judgements; that we should, or example, treat people to whom we are personally committed

better than strangers. More generally, it is observed that norms o ethical behaviour vary locally andcross-culturally as well as responding to institutional and contextual change. Transactions respond

to concrete and relational ethics and practice (Geisman et al., 2008).

The literature on eminist ethics is one source o thinking on relational ethics in health care (Baylis et al.,

2008). The eminist literature on care emphasises relationships as a key aspect o ethical behaviour,

noting the importance o attachment as a source o moral behaviour and identiying the limitations

o detached impartiality as a guide to morality in practice. The role o working relationships is tackled

in literature on emotions in health care. Nussbaum, a philosopher, and nurse-sociologists, such as

Pam Smith, have argued that emotions and ethics are deeply intertwined. Nussbaum (2001) argues

that emotions are central to the ability o a mature reasoning individual to make ethical judgements.Smith (1992) argues that nursing centrally involves emotional labour, i.e. the active use o emotion

or the purpose o caring or others. Her work draws on Hochschilds (1983, p. 7) denition o

emotional labour (in the context o air cabin crew) as the induction or suppression o eeling in order

to sustain an outward appearance that produces in others a sense o being cared or in a convivial

sae place. In other words, nurses must manage their emotions or others needs. Emotional labour

is not acting; to care eectively involves the management o genuine eeling. Smith urther argued

that to care eectively nurses must themselves be supported, a condition that is unmet i nurses

are working in under-resourced and/or hazardous conditions and without eective management

support.

The application o the concept o relational ethics in studies o midwiery emphasises the importance

o the relationship between midwives and women giving birth in promoting communication and

saety (Hunter & Deery, 2009). Midwiery in the United Kingdom has seen a debate about the

erosion o continuity o care or an individual by a named midwie, questioning whether this erosion

has links to midwives turning nasty (Robinson, 2000). This debate in the UK resonates with the

data collected by the current study.

2.2 Methods

The sample and data collection instruments

Fieldwork or the project was undertaken in our districts located in two contrasting regions o

Tanzania. In each region, the research included one urban and one rural district. Three wards in

each district and then two streets or villages in each ward were chosen that displayed contrasting

economic circumstances. Finally ten households were selected randomly along those streets or

villages. Households where no woman was pregnant and/or no woman had given birth in the last

ve years were replaced. A total o 240 households were selected, sixty in each district.


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Interviews with heads o households or their representatives in these 240 households collected

basic data on the households socio-economic conditions, while interviews with women collected

data on payments and maternal care, including birth experiences. In the sampled households all

eligible women were interviewed. In total, interviews were conducted with 248 women who had

given birth in the last ve years and/or were currently pregnant. The ve-year cut-o point was

applied to limit recall problems. The interviews captured inormation on the womens experiences o

antenatal care, care at birth, and post-natal care, including payments made and their perceptions

o the quality o care they received.

In addition, the eldwork also included health-care acility interviews that were conducted with

health workers in 59 health acilities in the selected districts. The health acilities in the survey wererom dierent tiers o the health system and were drawn rom three sectors public, private, and

those owned by aith-based organisations (FBOs). In total, 11 hospitals, 16 health centres, and

32 dispensaries were visited. Interviewees included medical directors and clinicians in-charge,

managers responsible or maternal care, and midwives. Some traditional birth attendants were also

interviewed.

Semi-structured questionnaires with provisions or in-depth probing were used in both household

and health acility interviews. In addition, or household interviews a separate structured questionnaire

was used to capture the households socio-economic characteristics. Fieldwork was undertaken in

September and October 2011.

As part o the interviews with women in household interviews and also with nurses, clinical ocers

and midwives in participating health acilities, we asked one question cold, that is without prompting,

concerning the meaning o ethical maternal care. The interviews were almost all conducted

in Kiswahili. For the women, the wording o the question in English and the instructions or the

interviewers were as ollows:

What do you think is ethical maternity care? (Do not prompt, encourage ideas and

suggestions, note all comments.)

For the nurses and clinical ocers in charge o maternity care, the question was:

What do you consider to be ethical maternal care Please explain and give examples

(Allow an unprompted answer.)

The unprompted answers to these questions are the particular ocus o this paper. The paper also

explores some o the responses to ollow up questions with probes. For the women, these ollow-

up questions were:

Looking back over the experiences we have been discussing, do you think you received

ethical care? I not, why not? I so, how and why? (Do not prompt, encourage ideasand suggestions, note all comments.)

You have mentioned .. (refer to previous answers). Do you think any o

the ollowing are also ethical issues as concerns maternal care? In what way, or why

not? (Prompt with those not mentioned, and record comments)


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Competent treatment including emergency care

Not suering harm

Respectul treatment, absence o humiliation/ abuse

Access to services without payment

Fairness, people being treated alike

Good/better treatment by sta who know you

Human rights / the right to maternal health care

Receiving value or money when you pay or services

For the midwives, nurses in-charge and clinical ocers, the ollow up questions were:

What do you consider to be ethical maternal care? Please explain and give examples.

(Allow an unprompted answer.)

In addition to the points you have just made, do you consider any o the ollowing

aspects o care to be matters o ethical concern? Please explain why?

Competencies o acility sta

Access to competent treatment including emergency care

Human rights / the right to health

Fairness, people being treated alike

Good/better treatment or patients known to sta

Supplying value or money services

Supplying services without payment

Respectul treatment o clients / patients

Doing no harm

Is it possible to provide ethical and eective maternity care when resources are

inadequate? What would have to change in order to make such care possible?(Prompts:)

In resources available

In the way the acility is managed

In the way midwives and other maternal health care sta are treated?

Ethical considerations

This study was undertaken with the approval o the National Health Research Ethics Review

Committee. In conducting primary data collection and analysing the ndings, eorts were made to

ensure anonymity and objectivity. Respondents were inormed about the objectives o the study,

and their inormed consent was obtained. Participants were assured o anonymity during the data

analysis and in the presentation o the ndings. Accordingly, data were coded to protect identities

and ensure privacy.


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The discussion in this section is based on an exhaustive analysis o the unprompted responses by

women to the unprompted questions on ethical maternal care detailed in the methodology. We

show that while some women did oer denitions o ethical care that draw on the kind o principles

ound in the medical ethics literature, this was not the dominant response. The dominant denitions

oered were relational, relating particularly to the avoidance o abuse by health care sta. A urther

important set o responses were unclassiable within the medical and nursing ethics literature: we

reer to these as contextual ethics and deend this concept below.

3.1 Principles o Medical Ethics

Some women mentioned a set o expected behaviours by nurses and other medical personnel thatcorresponded to, or were attributes o, some basic principles characterised in the medical ethics

literature. We outline these responses below2.

Fairness and equity

Twenty interviewees spontaneously mentioned airness in the way one is received and cared or by

the acility sta. Unprompted answers on ethical care included::

One [care] that is provided without discrimination. [148]

Fair treatment or all, as well as equality. [128]

Provide air services without being biased to anyone even i is your relative. [19]

Being helped with her problem without delay is the service with air treatment. [111]

Good services which are air and provided ree or everyone, so everyone who goes

to get services should be given services. [181]

The nurse receives people o dierent calibre, educated and non-educated, but they still

respect the patients. [9]

Thirty-our unprompted answers specied ree services as an aspect o ethical care. Some reerredto this as a right, since the government had mandated that care be provided or ree, but most

related it to airness in access without reerence to the ability to pay. Some linked it to the quality

o care, arguing that ree services should not be poor services. Strikingly, most o these responses

were rom women in one o the two regions only. Here are examples.

Not to be discriminated against based on money. [12]

Free delivery services including ree supplies. [107]

The service which even we who have low income can have access to without making

any payments and still get good service. [180]

It is the service which cares or clients/ patients rst and i they need money it is ater thecare is provided. [28]

Getting ree services as per government directives. [39]

Be free as per the government directives. [39]

2 The numbers in brackets at the end o each quotation are the unique reerence numbers or each respondent

3 Understandings o ethical maternalcare: Responses rom interviews with women


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Proessional responsibility and conduct

A second set o responses related to the principles o medical ethics concerned doing good,

and doing no harm. These were cast in terms o proessional and responsible behaviour by sta,

including condentiality. Respondents also placed particular emphasis on avoiding delays in order

to treat patients eectively. Here are examples.

Getting the right medicine. [1]

Responsibility, or example, a laboratory attendant must be very careul i he perorms

an HIV/AIDS test or a patient and gives improper results then he will be answerable.

[9]

Keeping patients secrets. [18]

Hard-working nurses. [31]

It has to be good and right or the person. It should not cause any problems or dangers

to the person seeking it. [202]

Not waiting long or the service at clinic. [20]

They should not be late to provide care, until a woman delivers on the foor. [38]

Nurses should be on standby to receive patients day and night, especially pregnant

women who go there or delivery and should be attended on time to avoid torture to

pregnant mothers. [56]

It is good care as required according to your condition. For example, when you go to

the hospital and have to be operated on, the doctors should be available and operate

ast otherwise you can have problems or even lose your lie. [7]

3.2 Relational or Caring Ethics

The ways in which nurses and other medical personnel relate to and treat or handle patients were

mentioned unprompted byalmost allthe women interviewed as aspects o ethical maternity care.

This was by ar the dominant type o response. Women mentioned relational issues ar more thanany other set o issues.

Non-abuse

The great majority o these relational issues concerned the way patients are received and handled by

health acility sta. A large number o women mentioned not being abused; others put it positively,

mentioning respect, care, dignity, politeness and love or patients.

Some typical reerences on the issue o abuse include the ollowing:

They should listen to our problems careully and should stop abusing us. [189]

Not to say abusive words to patients. Some nurses humiliate patients. This is not

allowed. [23]

Not to be ignored when in pain or to be abused. [193]

They should not humiliate us but respect us. [20]


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They should not be rude and they should respect patients and stop humiliating us

because they are also women. [38]

They should act like ellow women to us, instead o treating us rudely. [40]

Among the very many reerences to dignity, respect and caring behaviour were the ollowing:

Maternal care is about lie on this earth because without women delivering babies there

is no lie on earth. So ethical maternal care should be about caring or pregnant women

with due respect and treating them with dignity. [41]

Respectul treatment. [196]

A respectul and humble service o good quality. [212]

Proper reception when attending any health acility. [11]

Respect clients, be polite to them. [19]

When someone receives you with a good heart, talks to you nicely. [29].

They should care or us. [34]

Maternal health care that really cares or the pregnant women. [242]

Politely provided without any anger or ury. [130]

It is to do good things or mother and child. This includes hospitality and humbleness.

[4]

They must love me as a patient. [40]

For whole time when I went to receive services, the acility workers received me well

and politely. Hence this was ethical maternal health care. [45]

No bribery

There were just ten unprompted reerences to avoidance o bribery and corruption, including:

Not to ask or a bribe. [12]

The service which is not associated with giving or receiving corruption. The service

which ollows the rules; pregnant mothers are listened to and no bribery. [156]

Not asking or money by orce. [17]

They should talk to us nicely and prescribe medicine when we need it and not tell us

there are no medicines while they are there. [20]

Being listened to / getting adviceIt was also clear that women perceive their interaction with nurses and medical personnel in terms o

being listened to and getting advice and training on maternal health issues as key aspects o ethical

care. Participants responses that illustrate this important aspect o care include:

Ethical maternal care is the one whereby we are taught how to take care o our

pregnancies, to take care o the newly born baby and to prepare a better meal or the

newly born baby. [2]


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The nurses should care or us and listen to us. [139]

To be given good treatment, that means to be listened to and to be given appropriate

treatment. [21]

The nurses should listen to the pregnant women and give them good explanations. [3]

Good advice. [148]

I expect the healthcare provider, nurse or doctor to attend me gently, kindly because

I am in pain, and thereore take good care, listen to me and attend me accordingly.

[22]

A nurse should be close to the patient, listen to them, and not pretending to be busy

and leave patient without any help. [160]

To be close to patients especially during delivery time so as to assist them. [23]

Making the mother understand things politely (the nurses). [34]

A acility worker should be humble, caring and listen to patients. [211]

The nurses should listen to my problem and be ready to help. [42]

3.3 Contextual Ethics

In addition, many o the participants unprompted responses on what constituted ethical maternity

care, did not t into the two broad rameworks or assessing ethical care. Understanding what is

ethical can be relative and context specic, varying according to socio-economic situations and

prevailing cultural norms and values o a group o individuals. We thus consider the ollowing aspects

o ethical maternal care (as mentioned by the women interviewed) to constitute a third ramework

that we call contextual ethics.

Competence

Our academic and proessional adviser on midwiery or this project identied technical competence

as a core ethical issue in midwiery in Tanzania. This theme tends to be taken or granted in the

literature o high-income countries, but was mentioned by both women and sta in the current

study. Women also emphasised the importance o knowing what was available and what was not.

Here are some examples:

Nurses and doctors must be experts in their work. [232]

Reliable and experienced nurses and doctors. [163]

Nurses should have enough experience and knowledge. [233]

It is the service which has enough service providers to ull patients needs. [38]

The acility must have all the services, to reduce disturbance or the pregnant women,

and also they must inorm the clients i the services are not available at the acility but

it can be obtained elsewhere. [24]


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Availability o services and supplies

Availability o services and supplies

There were also many reerences to the availability o beds, supplies and key services such as

tests.

The service which makes sure a pregnant woman receives all tests which are required.

Medicine should be available at all health centres. [27]

Its the service in which a pregnant woman is given all tests. [191]

There should be enough supplies and all tests being conducted in the same acility. They

should stop directing patients to other acilities only or getting tests. [56]

Availability o all services at all times. [57]

This will be when the patients are given due attention according to their needs. I want to

give an example. When I delivered, the baby was put on bed together with three other

babies. We mothers were sitting down. You can imagine ater delivery to sit down with

stitches is very painul. [33]

Value or money

Finally, there were a ew unprompted remarks about the ethical importance o value or money:

Private facilities providing services equivalent to the money spent. [39]

Service should be provided for free; staff should not tell us to make payments. If chargedmoney you should get adequate services corresponding to the money paid. [8]


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The health care proessionals interviewed included midwives and the sta members in charge

o maternal care in each acility, whether a nurse/midwie or clinical ocer (two years o medical

training). The same three ethical rameworks as in the analysis o womens responses are used

or the analysis o sta perceptions o ethical maternal care. Unless otherwise stated, the data

presented are the unprompted responses to the question: What do you consider to be ethical

maternal care?

4.1 Those in Charge o Maternal Care

4.1.1 Principles of medical ethicsA ew o those in charge o maternal care indicated that they had received some education in the

standard principles o medical ethics. Three respondents reerred to the concept o doing no harm,

including:

Treating patients without doing harm. This is what ethical principles suggest. When a

patient comes to the health acility, she is looking or rescue o the problem she aces,

so i you add more problems to her (by harming) this is quite unethical. [2,17]3

Care that ensures both mother and new born are sae. [It] should ensure that no harm,

e.g. inections, is done to mother and child. [4,55]

Most, however, did not couch discussion o ethical problems in this language.

Proessional Responsibility

The themes o proessional responsibility, and o airness and non-discrimination, appeared strongly

in the responses o nurses in charge. Some in-charge emphasised doing the job properly or providing

good quality care. This category o responses included doing the job competently and completely in

all its aspects, according to guidelines, or example:

Proper nursing care (do all scientic procedures required). [1, 31]

Ability to use her/ his knowledge to attend the patient. [1,8]

One should prepare all the requirements, take all required tests ... and conduct delivery

as required. [2,13]

Try to identiy her problem, take the history, tests, all the necessary treat her or what

she has to be treated or. [4,52]

A related aspect was early identication o problems:

To report any complication immediately. [4,57]

Try as much as you can to reduce maternal death, look/spot danger signs early andreer the patient as soon as possible. [2,34]

Ask or assistance where the situation becomes complicated. [2,26]

3 Attributions: The rst number is the identier o the district, and the second number is the identier o the respondent.

4Understandings o ethical maternal

care: Responses rom interviews with nursesIN-CHARGE, midwives and clinical ofcers


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This linked to relevant sta attitudes, such as willingness and commitment to the task:

Midwives to be willing to do the job properly as required. [1,11]

Have qualied and skilled midwives who are also committed so that problems are

identied in early stages o pregnancy. [1,22]

One respondent refected on responsibility as ollows:

The service provider has to be responsible ... and where you are not competent

involve others who know, like other midwives and doctors ... as a service provider you

should know and understand yoursel and your limits. [2,28]

Three respondents linked ethical care to patients saety. For example:

The most important thing is to make sure that delivery is sae or both mother and

child. [3,40]

Other respondents identied aspects o care that were associated with ensuring patients saety:

First, a woman should be kept in saety, privacy, cleanliness, quality and using sterilized

equipment. [3,43]

Privacy woman would like to be served by someone who can keep their secrets.[3,44]

Seven respondents mentioned condentiality, or example:

Condentiality is very important in this job and is a key aspect in providing ethical

treatment. [2,29]

Just our respondents mentioned cleanliness e.g.:

Cleanliness is also important. [4,49]Ensuring clean environment and equipment to prevent inection. [1,3]

Several respondents emphasised ollow-through to sae post-natal care (PNC):

Right rom ANC, a pregnant mother should get someone who will take good care

o her; take (give) all the tests, treatment i any When she comes or delivery, all

the tests have to be done (history taken) and just in case she gets an emergency,

some other things should be sae and observed, and the mother and baby have to be

observed at least within the rst 24 hours ater birth. [3,41]

Finally, two in-charges mentioned as ethical issues the work burden o this proessional commitment

on the sta:

Should be fexible to work long hours and day and night shits [4, 46]

Ability to work extra hours [4,53]


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13

Fairness and equity

The second category o general ethical principles reerred to by these interviewees was airness or

equity, and its link to rights. There were ewer o these responses: ten out o 49 respondents. Some

o these interviewees made very general statements.

For example:

Equality, all human beings are equal, so they should be treated equally without

discriminating one group. [2,17]

Other respondents oered detail, such as:

Must not display any avouritism to patient regardless o their income level. [2,24]

There should be no discrimination, e.g., treating better those who you know or have

better education or with more income. [3,34]

Not to stigmatise the mother or whatever reason. [2,25]

Treat everyone as an individual not [as part o] a group. [1,31]

Only one o these respondents spontaneously mentioned ree services as an element o ethical

maternal care, in the context o saving the lie o mother and child:

This includes serving them [women] reely as the government circular directs. [3,41].

4.1.2 Relational and caring ethics

As in the interviews with women, many o the unprompted responses o those in-charge o maternity

ocused on relational issues o politeness, non-abuse, communication and trust. A recurrent theme,

which refects the literature on the link between emotions and ethics was the need to love midwiery

in order to do it well, e.g.

You have to love your job and your patient. [1,12]

The service provider should rst love their work; use their knowledge and skills to serve

clients. [2,26]

Non-abuse and respect

The womens responses in the previous section implied widespread expectations o abuse and

disrespect. Some o the comments o the in-charges indicated an awareness o this. While the

majority o women reerred to this set o issues, a much smaller proportion o the in-charges did so.

Comments that recognised the existence o abuse included:

Do not use orce, not to harm the client. [2,26]

Dont shout at the mother. [2,13]The nurse should be kind, use the language that is not harsh and should respect the

woman. [2,27]

Not to be rude to patients. [1,11]

Over a quarter o all respondents expressed the issue o not abusing clients positively in terms

o polite language. In some acilities, this was the sole unprompted response o the in-charge.

For example:


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14

Polite language when attending to patients. [4,48]

Language to patient should be good. [3,44]

Speak well to the clients. [2,26]

There is a need or polite communication to patients. [1,11].

Good customer care, show care to patient, treat them politely. [1,31]

Where women is received and attended to in a polite way. [2,23]

Just our responses recognised the underlying issue o respect, as raised by the women interviewees,

e.g.

To pregnant and delivering women, show them the respect. [2, 30]

Respectul and not ormal. [2,19]

Eleven others described ethical care as being kind or caring e.g.:

Service where one is kind to the patient. [4,47]

Should be caring and showing love to patient. [4,57]

Service where sta are welcoming. [3,33]

Should be fexible and kind person. [4,50]Must be concerned with the well-being o the patient. [2,24]

Be a riend to a patient. [4,58]

One mentioned truthulness. [2,14]

Communication, listening and teaching

Some o the responses above reer explicitly to relationships with patients. About a quarter o

respondents emphasised listening and communication as well as talking:

The most important thing is how you communicate with patients. Language matters in

this job. This is our main challenge. [1,10]

Should listen to the patient attentively. [4,57]

Listen to client and understand them., give them chance to tell you what they eel.

[2,26]

It is important to provide maximum attention to the patients. [1,1]

Where care giver is able to ask, seek inormation and learn. [3,35]

The service provider should greet the woman, give her explanations i she asks

question, respond to them all and give her the right responses. [2,21]

Listen and to care or the client. Allow them (clients) to tell what they have, give them

advice and provide help/assistance as required. [2,25].

To have good relationships with other members o the pregnant womans amily.

[3,42]

Communication was particularly essential to the collaboration required or sae delivery:


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15

You have to have good communication with the patient so that you can collaborate

during delivery. [1,12]

This in turn required close attention to the patients condition and progress e.g.:

Receiving well the pregnant mother, asking her questions relating to her labour,

examining her to see the extent o her labour. From there you will see whether the

labour has advanced enough to oer her place to rest waiting or delivery. [2,17]

Give proper directions, keep close observation, monitor the labour [1,13]

This kind o communication could generate trust:

A woman should be ree to talk to the service provider, handle the woman with care

and allow her to trust you and eel sae in your hands. [3,38]

Many in-charges emphasised appropriately teaching, inorming and counselling their patients., e.g.

I it involves testing, all tests should be conducted, and it should be explained well

to her Provide her with counselling and inorm her o the importance o whatever

services she gets, i there are any side eects she should expect, and the need or

return visits i any. [2,27]

Midwives who are capable o giving proper health education so that women are aware

o risk actors. [1,22]

It is where a woman is well advised and counselled/educated on how to bring up the

child, on nutrition and watching the childs progress. Taking the weight [o the baby]

and tests as required and explaining to the mother accordingly. [2,30]

Do not orce them to test or things you have not well explained to them and the

benets and reasons or that. [2,30]

Give her proper explanation give her proper and right advice. For example, i its

a pregnant woman complaining o stomach pains, as a nurse you have to test andcheck whether she is in labour and i she has to go back home. Advise her to return

to the hospital or dispensary should she eel any pains or changes and that has to be

immediately. [4,52]

Delay, bribery and emotional pressure

In the womens interviews, links were made in response to the question on ethics between being

delayed and neglected, and being asked or bribes or to make unexpected payments. There was

some recognition o these interconnected relational issues in the responses o those in charge o

maternity.

There was recognition o the issue o delay, and that the delays did not arise solely rom sta

shortages:

It [care] has to be provided at the right time. [2,21]


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16

Care should be attentive and prompt, e.g., do not keep woman waiting unnecessarily.

[3,34]

The very ew comments on bribery were linked by some to delays in care and abuse:

You are not demanding bribes. In other places, a pregnant woman is not well-attended

i she does not give something. [4,47]

Should not be corrupt and ask or money rom patients. [1,8]

Not to charge the client when its not part o the services. For example, even i the

woman comes without requirements [that is, essential supplies] but she needs your

service at that particular time, one should not hesitate to provide such services.

[1,13]

Finally, a ew comments recognised the pressure the sta were under, and the need to manage

their own emotions and to cope:

Be able to handle your emotions. [2,26].

Also use polite language and control our temper even i patients are dicult. [4,58]

Should respect onesel and the woman you are serving. [2,28]

Not alcoholic [the sta] nor use alcohol during working hours. [4,46].

4.1.3 Contextual ethics

The discussion o abuse and bribery interlinks, as in the interviews with women, to contextual

issues that were repeatedly reerred to in the unprompted responses o those in charge. As in the

interviews with women, the two major issues raised were technical competence o the sta and the

availability o essential supplies.

Competence

Technical competence was emphasised by 15 o the interviewees as essential or ethical care. Forexample:

The service provider should also be knowledgeable about the service they are providing

because without that knowledge, the mother wont be served properly and its not

right or both the service provider and the person receiving services. [2,25]

Attendants must also know the service they are providing. For instance, i the child

is not in a good position, the service provider must be in a position to explain to the

mother very well about such a condition. [2,30]

It is important to be technically competent and check all the vital signs regularly.

[4,49]Be able to identiy the problems at an early stage. [3,44]

Ability to spot and handle emergency cases. [1,8]

Have sta with knowledge and skills. [3,33]

The hospital and the service providers should be capable to help in case o emergencies.

[3,44]

The requency with which this issue was raised by in-charges refects how oten acilities do not


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17

have enough competent sta.

The stang level needs to be adequate and especially a specialist in case o emergency

should be within reach.[1,2]

Should be able to learn new developments in the eld. [1,8]

She/he should be fexible to learn and work in a team i.e. team player. [1,8]

One respondent expressed anxiety about the recent decision to reduce the training o nurse

midwives to two years:

Should be technically competent especially on the practical part. The two-year course is a disaster.When you employ them they are not competent. There is a need to resist this program. [4,59]

Availability o supplies and basic inrastructure

As in the interviews with women, the availability o essential supplies, such as gloves and medicines,

was requently raised by in-charges when asked about ethical care:

All supplies and equipment should be in order. [1,2]

Availability o supplies and equipment or delivery and EmOC [1,8]

You have all essential supplies. [4,45]Has adequate supplies or maternal care. Government commitment on maternal

health as priority should be seen in terms o having no shortages o supplies, e.g.,

government says one should have our pairs o bed sheets but in reality very little

money is given or this. [1,22]

Other basic inrastructure, such as beds and water, were also identied as essential requirements

or ethical care to be provided. Water is oten a serious constraint. As a result, ethical care may not

be achieved.

The mother and baby have to be observed at least within the rst 24 hours aterbirth, although here we do not keep them or 24 hours. We keep them or 6-12 hours

because o the shortage o beds (small space and the women who come or the

service are many). [3,41]

Patient should be provided with all the required services when it is possible. [2,29]

4.2 Midwives

The quotations in the preceding section were all rom sta members in charge o maternal services.

We also interviewed working midwives at the acilities. In a ew acilities, the only midwie available

was also the person in charge; in some other acilities, no midwie was on sta.

In this section, we assemble, under the same three ethical rameworks, the responses o midwives

to the unprompted question concerning the nature o ethical maternal care. In general, the midwives

ound it harder than those in charge to respond to the unprompted open question. They had more

to say in response to the prompts by the interviewer.


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18

4.2.1 Ethical principlesIn these interviews there is a smaller proportion o statements o general principles. There was one

general statement about doing no harm:

It should not cause negative impacts to the woman. [3,37]

Proessional responsibility

Otherwise, over a quarter o the midwives interviewed emphasised doing the job properly. For

example:

It should be right depending on the age o the pregnancy, age o a mother and the

number o deliveries she has had. [2,25]

Following all procedures is most important. This involves examining her, giving her

proper tests and necessary services. [3,40]

Conduct all the necessary tests. [3,41]

PNC [post-natal care] has to be as required. Observe her within 24 hours ater delivery

then at two weeks and six weeks ater [birth] and be sure that she has gone back to

normal. [3,39]

Ethical services on maternal health starts rom the rst day a pregnant woman comes

or ANC. You have to give her ethical health services because she needs good healthcare which includes medical tests, treatment and medicine. You have to look at her

historical health status. [4,56]

When she comes into labour, i she was well prepared during ANC, it will not be a

problem. She will only need little reminders, the same will be with PNC. [3,41]


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19

This required an attitude o dedication and concern or saety.

The woman expects to be sae and have a child that is sae. The duty o a service

provider is to help in order to achieve these goals. [3,34]

You have to be keen and careul on how to conduct your work. [1,7]

I have to like my job and be dedicated. [2,23]

The service provider must love her job and this gives her chance to provide the right

services, practice as you were taught, not to do as one eels like; ollow the guidelines;

and the provider to seek assistance whenever they are not. [3,35]

Midwives also identied some o the same aspects o proessional conduct as the in-charges:

Condentiality, or instance, not to let a womans problems be known to everyone,

even those not concerned. [2,18]

Privacy, not leaving woman in a crowd with others during delivery. [1,3] [this midwie

was also in-charge]

Fairness and equity

Six midwives spontaneously mentioned aspects o airness, including:

Care that ensures airness without saying this person is more able than someone else.

[1,8]

Segregating patients is not ethical. All patients are supposed to be served equally.

[4,53]

We have to respect our patients regardless o their income levels/or any other status.

[2,23]

Giving care without being air or unair to one client and not another ... also maternal

health services are the right o every pregnant woman, so in any situation you have to

provide good care. [4,56]

One midwie linked the issue o airness to payment or care:

Free service is ethical. [4,53]

4.2.2 Relational and caring ethics

Many midwives cited relational aspects o their work, especially politeness, listening, and teaching/

education, and linked these aspects to patient saety.

Non-abuse and respectFiteen o the midwives interviewed mentioned issues o non-abuse and respect. Comments

included:

Use polite language to patient even i the patient is non-cooperative. Treat her with

care and nally you get her to deliver saely. [2,29]

To be polite to relatives who escort the expecting mother. [1,11]


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20

Do not be rude to patient and assist with all your heart and ability. [1,4]

I you have given a patient a date/appointment to come back and i she does not show

up do not be upset the day the patient shows up. [1,4]

Good language throughout the time o service required. [4,43]

It should be riendly, respectul o woman and sae or her. [3,32].

One respondent recognised acility constraints:

You must use good language to patients, but sometimes it is hard to be attached

given our overcrowding situation. [1,22]

Communication, listening and teaching

Listening well and establishing communication were mentioned a number o times as key to ethical

maternal practice.

You have to listen to the patient attentively. [1,4]

It has to involve listening to what the woman has to say, her problems and to assist

her solve her problems. For example, i a woman comes late and in labour and the

oces are closed. As a rule here, i a woman comes in such a state, you have to call

the doctor (1,2, 3rd

birth or has a scar [previous C-section] who will call in the theatreteam And i as a nurse on duty you have not done the right thing, then its a problem.

[4,59]

The largest set o responses concerned inorming and educating the women who come to the

acility. They included:

It requires the service provider to tell the woman and counsel the woman on sae

pregnancy and delivery, and where the woman should get services and at what stage.

[2,18]

The women has to be tested rst and conrm the pregnancy and get a ull history,counsel her and prepare her well to understand what is necessary and required or

her. [3,32]

Tell her o all the dangers and treat her as required. [3,32]

Giving women needed inormation, e.g., ater delivery telling her the sex o the baby

and congratulating her. [4,48]

To examine pregnancy and advise clients on progress or problems i any. Guide a

pregnant woman on how to take care o her pregnancy. Advise her on importance o

vaccination. [3,44]

Giving eedback to relatives who come with a pregnant mother and telling them whatis expected i anything. [1,9]

The mother who comes or delivery should know what she is coming to do and should

cooperate with the nurse. [4,54]

It was recognised that eective communication required an attitude o care and attention so as to

build a good relationship with the mother.


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21

A good reception is very important. This should be accompanied with allowing the

mother to explain how she eels. [3,43]

Advising how to lie on the bed, assisting her during delivery and being careul to avoid

rupture. [3,40]

The rst thing is love to pregnant women. Educating them to be clean and to properly

clean their babies. Attending PNC is another important thing that is needed. [4,53]

Good relationship between those providing care and those seeking care. [1,10]

It [service] has to be riendly and when it starts by being riendly, it will end up being the

required one since you will have a chance to understand the person you are serving.

[2,28]

Advise her accordingly, e.g., on amily planning and other services that she may need.

[3,39]

Ethical care also demands proper attention to a womans practical needs:

To provide care or the baby ater they provide a woman with a paper evidencing that

the baby is born in our acility. This helps to get birth certicate. [3,40]

Delay, bribery and emotions

There was little recognition in the midwives spontaneous responses o this set o relational issuesthat were o great concern to the women interviewed. Four midwives mentioned avoiding delay and

inattention, including:

Sta should be motivated to do the job well and not be thinking o other things.

[4,58]

One respondent noted that this meant fexibility and being on call:

I should be o help at any time in case o emergency. [2,23]

No one mentioned bribery explicitly, but one nurse midwie said:

For instance, i she cannot aord to pay, do not deny her the services. [2,18]

One midwie mentioned the importance o controlling ones own emotions to provide good care:

The person in pain will always say anything; be patient, understanding and provide the

right care/treatment. [3,41]

4.2.3 Contextual ethics

The midwives commented even more oten than the in-charges about the contextual issues already

identied and discussed.


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22

Competence and stafng

Competence, i.e. the importance o knowing what you are doing was a common concern among

the midwives interviewed. Comments included:

The midwie having the required skills and qualications to do the right job. [2,29]

Health workers should be well-trained/ equipped or the local level. [1,31]

It is important or local TBAs (traditional birth attendants) to be given a modern training

to avoid delays and unnecessary emergencies. [1,31]

Need to have qualied midwies and doctors. [1,5]

Skilled sta who are able to diagnose and identiy any complications. Where sta are

able to make ollow up. [4,55]

During delivery, you must know whether the woman can push or i she will require a

C-section, and reer them to some other tests and hospitals on time. [3,39]

Three respondents remarked that this required both skilled and adequate numbers o sta. It also

required proper organisation: two mentioned team work and reerral:

Availability of supplies

Lack o supplies was also a repeated ethical concern; eight midwives highlighted this issue.

Responses included:

There should be adequate supplies and drugs. The government has to ensure this.

[1,8]

Good preparation including having enough gloves, mackintosh, thread and enough

clothes. [3,38]

Inrastructure and equipment were also a concern:

Inrastructure should be adequate, e.g., big labour room. [4,58]It is important to have access to an ambulance just in case there are any emergencies.

[4,54]

Finally, there was recognition that lack o supplies constrained what could be ethically provided:

I supplies are available, allow her to get ree service as per government directives

without segregation. [3,43]

Free service is ethical, but here, since it is public, most patients have to pay in order

or the organisation to be able to run its activities. [4,53]

Provide the services i they are available. [2,18]

I you do not have all the services, reer her to where she will get services. [3,32]


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23

We consider here, with reerence to some o the evidence rom the ollow up questions, the

interconnections between certainn aspects o maternal health care that both pregnant women and

health care sta identied as ethical. We examine three sets o interconnections: emotions and

abuse; avouritism and bribery; and supplies and payments. We end with a refection on the dangers

o ethical vicious circles in maternal health care.

Emotions and abuse

Interviews with women, including the ollow-up questions on ethics, conrmed the widespread

experience o rudeness and abuse. Women strongly linked ethical care to not being abused or

treated harshly/rudely and to being listened to, e.g.

No, in government hospitals, I never got services ethically. The nurses are abusive/

insulting, they chase women away. [10]

The nurses mistreat and abuse women. Student nurses are good and serve people

well with smiling aces. The experienced nurses are bad and abusive. [24]

Yes, it was ethical because I received all services including blood tests without being

charged or them and even the nurses were not harsh to me they listened to me

careully and nicely. [127].

Nurse midwives in their interview responses identied both the practical and emotional pressurethey are under. Their comments included the importance o being able to handle your emotions,

and to control your temper even i patients are dicult. Some indicated they were struggling to

cope. In response to ollow up questions, nurses said:

I someone is overworked he or she can never provide good service. [1,2]

We are overworked, paid low salaries and lack key equipment in our acility. [1,22].

I there are no essential supplies you are worried because you could be at risk and also

you do not have peace o mind. We as midwives should try to cope with the situation

and do our job since this is a job that requires one to have a calling. However, we

should push or improvements. [1,10]

In the second paper in the series rom the project Ethics, payments and maternal survival4 we

explore these pressures on nurses in much more detail. As noted above, some women also noted,

without excusing abuse, that nurses were struggling to cope.

Favouritism and bribery

There is extensive commentary in the womens interviews linking bribery to avouritism and

discrimination. In response to the ollow-up questions, women elaborated on this connection and

many criticised it.

It is not good to treat patients dierently. We should stop the culture o avouritism.

[146]

I you dare to ask why some o us are taken to the doctor through the back door you

will be abused to death. [209]

In our dispensarywhen a pregnant woman goes or delivery she will be orced to give4 Tibandebage et al Empowering Nurses to Improve Maternal Health Outcomes, 2013

5 Discussion


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24

money or git to the nurse ... [or] ... the nurse will abuse her so much. [83]

I someone is able to give the nurse some little money then she will get a better service

although corruption is not ethical. [150]

I never got ree service. I wonder i on earth, especially in Tanzania, there is a ree

service. In act corruption has taken root. When you do not have money to bribe like

me, a pregnant woman will be given poor service. [30]

For our nurses and doctors, money comes rst then dignity. [152]

Many women, as cited above, argued that avouritism was not ethical even when it was about

avouring people you know. One respondent to a ollow-up question said:

I do not think it is necessary to attend someone nicely simply because youre riends.

What i we are not known to each other? Or what i we are not riends? It means I will

die. That is not ethical. [91]

On the other hand, a ew women disagreed. For these respondents, it was proper to treat those

whom you know better.

It is a good thing or a doctor to help his/her relative or riends. To me, I see it as a

normal thing, and am used to it. That is why I see it as a normal thing. [210]

I they know me why wouldnt they give good treatment to me? That is the meaning oknowing each other, so it is ethical. [74]

It is ethical because this is the advantage o knowing people. It is a return on investment.

[86]

Supplies and payments

Extreme supply shortages in some acilities and areas meant that women were paying or supplies

and tests privately. Nurses were then accused (rightly or not) o selling supplies:

The government has announced ree services to pregnant mothers while we areacing shortages ..unullled expectations cause conficts between health workers and

patients. [ 2,29]

In a womans view thereore:

The ANC services were not ethical because [o the lack o equipment or] pregnancy-

related tests and the acility was not ready to reund the payments or these tests in a

private acility. [21]

Given chronic supply shortages in health acilities, the public commitment by the government to

provide ree maternal health care has thus set up conficts between expectations and observed

practices.

Ethical vicious circles


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25

The level o stress in these interviews was striking. There were acute gaps between the aspirations

or ethical care o both women patients and many maternal health care workers, and a quite

widespread experience o rudeness, abuse and inormal payments. Thereore it is possible to see

how in some acilities an ethical vicious circle can occur (Figure 1).

Figure 1: Ethical vicious circles

Shortages o supply and skills eed patterns o payment e.g. private payment or supplies. They

also eed abuse, as people pay to jump queues and obtain scarce resources. Abuse and inormal

payments also then interact, as many o the responses illustrate.

However, these circles are not inevitable. There was a set o perceptions shared by both women and

maternal sta that these conficts were partly rooted in the contextual ailings o lack o competent sta

and essential supplies, and some sympathy among women or the conditions under which nurses

were working. Facilities that received better reviews rom women had generally simultaneously

tackled the supply management problem and interaction between bribery and abuse.

In summary, the key ndings o this paper are two. First, that ethics in maternal health care in

Tanzania is widely understood in a relational sense, that is, to concern proper proessional and

equitable relationships between health care sta and pregnant women. And, second, that the

contextual issues o sta and supply shortages and their implications, are strongly perceived by

both sta and women to be matters o serious ethical concern.


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26

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Books

Researching Poverty in Tanzania: problems,

policies and perspectives

Edited by Idris Kikula, Jonas Kipokola, Issa Shivji,

Joseph Semboja and Ben Tarimo

Local Perspectives on Globalisation: The African

Case

Edited by Joseph Semboja, Juma Mwapachu and

Eduard Jansen

Poverty Alleviation in Tanzania: Recent ResearchIssues Edited by M.S.D. Bagachwa

Research Reports

12/4 Factors Affecting Participation in a Civil

Society Network (Nangonet) in Ngara

District

Raphael N.L. Mome

12/3 The Instrumental versus the Symbolic:Investigating Members Participation in Civil

Society Networks in Tanzania

Kenny Manara

12/2 The Effect of Boards on the Performance

of Micronance Institutions: Evidence from

Tanzania and Kenya

By Neema Mori and Donath Olomi

12/1 The Growth of Micro and Small, Cluster

Based Furniture Manufacturing Firms and

their Implications for Poverty Reduction inTanzania

Edwin Paul Maede

11/2 Affordability and Expenditure Patterns for

Electricity and Kerosene in Urban

Households in Tanzania

Emmanuel Maliti and Raymond Mnenwa

11/1 Creating Space for Child Participation in

Local Governmence in Tanzania: Save the

Children and Childrens CouncilsMeda Couzens and Koshuma Mtengeti

10/5 Widowhood and Vulnerability to HIV and

AIDS-related Shocks: Exploring Resilience

Avenues

Flora Kessy, Iddy Mayumana and Yoswe

Msongwe

10/4 Determinants of Rural Income in Tanzania:

An Empirical Approach

Jehovaness Aikaeli

10/3 Poverty and the Rights of Children at

Household Level: Findings from Same and

Kisarawe Districts, Tanzania

Ophelia Mascarenhas and Huruma Sigalla

10/2 Childrens Involvement in Small Business:

Does if Build youth Entrepreneurship?

Raymond Mnenwa and Emmanuel Maliti

10/1 Coping Strategies Used by Street Children

in the Event of Illness

Zena Amury and Aneth Komba

08.6 Assessing the Institutional Framework

for Promoting the Growth of MSEs in

Tanzania; The Case of Dar es Salaam

Raymond Mnenwa and

Emmanuel Maliti

08.5 Negotiating Safe Sex among YoungWomen: the Fight against HIV/AIDS in

Tanzania

John R.M. Philemon and Severine S.A.

Kessy

08.4 Establishing Indicators for Urban

Poverty-Environment Interaction in Tanzania:

The Case of Bonde la Mpunga, Kinondoni,

Dar es Salaam

Matern A.M. Victor, Albinus M.P. Makalle

and Neema Ngware

08.3 Bamboo Trade and Poverty Alleviation

in Ileje District, Tanzania

Milline Jethro Mbonile

08.2 The Role of Small Businesses in Poverty

Alleviation: The Case of Dar es Salaam,

Tanzania

Raymond Mnenwa and Emmanuel Maliti

08.1 Improving the Quality of Human Resources

for Growth and Poverty Reduction: TheCase of Primary Education in Tanzania

Amon V.Y. Mbelle

07.2 Financing Public Heath Care: Insurance,

User Fees or Taxes? Welfare Comparisons

in Tanzania

Deograsias P. Mushi

Publications by REPOA


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07.1 Rice Production in the Maswa District,

Tanzania and its Contribution to Poverty

Alleviation

Jerry A. Ngailo, Abiud L. Kaswamila and

Catherine J. Senkoro

06.3 The Contribution of Micronance

Institutions to Poverty Reduction in

Tanzania

Severine S.A. Kessy and Fratern M Urio

Publications by REPOA

06.2 The Role of Indigenous Knowledge inCombating Soil Infertility and Poverty in the

Usambara Mountains, Tanzania

Juma M. Wickama and Stephen T.

Mwihomeke

06.1 Assessing Market Distortions Affecting

Poverty Reduction Efforts on Smallholder

Tobacco Production in Tanzania

Dennis Rweyemamu and Monica Kimaro

05.1 Changes in the Upland Irrigation Systemand Implications for Rural Poverty

Alleviation. A Case of the Ndiwa Irrigation

System, Wes Usambara Mountains,

Tanzania

Cosmas H. Sokoni and Tamilwai C.

Shechambo

04.3 The Role of Traditional Irrigation Systems in

Poverty Alleviation in Semi-Arid Areas: The

Case of Chamazi in Lushoto District,

Tanzania

Abiud L. Kaswamila and Baker M. Masuruli

04.2 Assessing the Relative Poverty of Clients

and Non-clients of Non-bank Micro-nance

Institutions. The case of the Dar es Salaam

and Coast Regions

Hugh K. Fraser and Vivian Kazi

04.1 The Use of Sustainable Irrigation for

Poverty Alleviation in Tanzania. The Case of

Smallholder Irrigation Schemes in Igurusi,

Mbarali DistrictShadrack Mwakalila and Christine Noe

03.7 Poverty and Environment: Impact analysis

of Sustainable Dar es Salaam Project on

Sustainable Livelihoods of Urban Poor

M.A.M. Victor and A.M.P. Makalle

03.6 Access to Formal and Quasi-Formal Credit

by Smallholder Farmers and Artisanal

Fishermen: A Case of Zanzibar

Khalid Mohamed

03.5 Poverty and Changing Livelihoods of

Migrant Maasai Pastoralists in Morogoro

and Kilosa Districts

C. Mungongo and D. Mwamupe

03.4 The Role of Tourism in Poverty Alleviation in

Tanzania

Nathanael Luvanga and Joseph Shitundu

03.3 Natural Resources Use Patterns and

Poverty Alleviation Strategies in the

Highlands and Lowlands of Karatu and

Monduli Districts A Study on Linkages and

Environmental Implications

Pius Zebbe Yanda and Ndalahwa Faustin

Madulu

03.2 Shortcomings of Linkages Between

Environmental Conservation and PovertyAlleviation in Tanzania

Idris S. Kikula, E.Z. Mnzava and Claude

Mungongo

03.1 School Enrolment, Performance, Gender

and Poverty (Access to Education) in

Mainland Tanzania

A.V.Y. Mbelle and J. Katabaro

02.3 Poverty and Deforestation around the

Gazetted Forests of the Coastal Belt of

TanzaniaGodius Kahyarara, Wilred Mbowe and

Omari Kimweri

02.2 The Role of Privatisation in Providing the

Urban Poor Access to Social Services: the

Case of Solid Waste Collection Services in

Dar es Salaam Suma Kaare

02.1 Economic Policy and Rural Poverty in

Tanzania: A Survey of Three Regions

Longinus Rutasitara

01.5 Demographic Factors, Household

Composition, Employment and Household

Welfare

S.T. Mwisomba and B.H.R. Kiilu


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01.4 Assessment of Village Level Sugar

Processing Technology in Tanzania

A.S. Chungu, C.Z.M. Kimambo and T.A.L.

Bali

01.3 Poverty and Family Size Patterns:

Comparison Across African Countries

C. Lwechungura Kamuzora

01.2 The Role of Traditional Irrigation Systems

(Vinyungu) in Alleviating Poverty in Iringa

Rural District

Tenge Mkavidanda and Abiud Kaswamila

01.1 Improving Farm Management Skills for

Poverty Alleviation: The Case of Njombe

District

Aida Isinika and Ntengua Mdoe

00.5 Conservation and Poverty: The Case of

Amani Nature Reserve

George Jambiya and Hussein Sosovele

00.4 Poverty and Family Size in Tanzania:Multiple Responses to Population

Pressure?

C.L. Kamuzora and W. Mkanta

00.3 Survival and Accumulation Strategies at

the Rural-Urban Interface: A Study of Ifakara

Town, Tanzania

Anthony Chamwali

00.2 Poverty, Environment and Livelihood along

the Gradients of the Usambaras on

TanzaniaAdolo Mascarenhas

00.1 Foreign Aid, Grassroots Participation and

Poverty Alleviation in Tanzania:

The HESAWA

Fiasco S. Rugumamu

99.1 Credit Schemes and Womens

Empowerment for Poverty Alleviation: The

Case of Tanga Region, Tanzania

I.A.M. Makombe, E.I. Temba and A.R.M.Kihombo

98.5 Youth Migration and Poverty Alleviation: A

Case Study of Petty Traders (Wamachinga)

in Dar es Salaam

A.J. Liviga and R.D.K Mekacha

98.4 Labour Constraints, Population Dynamics

and the AIDS Epidemic: The Case of Rural

Bukoba District, Tanzania

C.L. Kamuzora and S. Gwalema

98.3 The Use of Labour-Intensive Irrigation

Technologies in Alleviating Poverty in

Majengo, Mbeya Rural District

J. Shitundu and N. Luvanga

98.2 Poverty and Diffusion of Technological

Innovations to Rural Women: The Role of

EntrepreneurshipB.D. Diyamett, R.S. Mabala and R. Mandara

98.1 The Role of Informal and Semi-Formal

Finance in Poverty Alleviation in Tanzania:

Results of a Field Study in Two Regions

A.K. Kashuliza, J.P. Hella, F.T. Magayane

and Z.S.K. Mvena

97.3 Educational Background, Training and Their

Inuence on Female-Operated Informal

Sector EnterprisesJ. ORiordan. F. Swai and A.

Rugumyamheto

97.2 The Impact of Technology

understandings of ethics in maternal health care: an exploration of evidence from four districts in...

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